PC-22.4 (Rev. 12-2000) PROBATE COURT OF FRANKLIN COUNTY, OHIO LAWRENCE A. BELSKIS, JUDGE JUDGE ERIC BROWN IN THE MATTER OF , MINOR CASE NO. REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM Pursuant to Entry filed and on the accompanying vouchers. , , the proceeds have been paid as shown below Gross Proceeds $ Less: Medical expenses $ Reimbursement of suit expenses to $ Attorney fees to Loss of service to $ $ Other: Total $ $ Net Proceeds Deposited pursuant to R.C. 2109.13 Form 22.3 attached $ Delivered to legal guardian of the estate , Delivered to parent and natural guardian , Delivered to the person by whom the minor is maintained , Structured - see documents previously filed Balance $ $ $ $ -0- $ Attorney for Fiduciary Attorney Registration No. Fiduciary ENTRY The above report of distribution is hereby approved and the applicant is discharged from further responsibility. Date LAWRENCE A. Brown Judge Eric BELSKIS Judge FORM 22.4 — REPORT OF DISTRIBUTION AND ENTRY MINOR'S CLAIM American LegalNet, Inc. www.FormsWorkflow.com